Should physicians attend out-of-hospital cardiac arrests?

Abstract

Emergency Medical Systems (EMS) across the world vary in their configurations. Within developed countries a major difference is whether the EMS service is physician-led or paramedic-led, with evidence to support both models. 1 Botker M.T. Bakke S.A. Christensen E.F. A systematic review of controlled studies: do physicians increase survival with prehospital treatment?. Scand J Trauma Resusc Emerg Med. 2009; 17: 8 Crossref PubMed Scopus (62) Google Scholar , 2 Garner A.A. Mann K.P. Fearnside M. Poynter E. Gebski V. The Head Injury Retrieval Trial (HIRT): a single-centre randomised controlled trial of physician prehospital management of severe blunt head injury compared with management by paramedics only. Emerg Med J. 2015; 32: 869-875 Crossref PubMed Scopus (45) Google Scholar Despite different ideas as to which profession should have primary responsibility for the care of patients prehospital, all EMS aim to improve survival from out-of-hospital cardiac arrest (OHCA). 3 Lindner T.W. Soreide E. Nilsen O.B. Torunn M.W. Lossius H.M. Good outcome in every fourth resuscitation attempt is achievable—an Utstein template report from the Stavanger region. Resuscitation. 2011; 82: 1508-1513 Abstract Full Text Full Text PDF PubMed Scopus (126) Google Scholar , 4 Perkins G.D. Lockey A.S. de Belder M.A. Moore F. Weissberg P. Gray H. National initiatives to improve outcomes from out-of-hospital cardiac arrest in England. Emerg Med J. 2016; 33: 448-451 Crossref PubMed Scopus (53) Google Scholar This has led to widespread adoption of advanced life support (ALS) as the standard of care for OHCA in modern EMS. 5 van Schuppen H. Bierens J. Understanding the prehospital physician controversy. Step 1: comparing competencies of ambulance nurses and prehospital physicians. Eur J Emerg Med. 2011; 18: 322-327 Crossref PubMed Scopus (25) Google Scholar , 6 von Vopelius-Feldt J. Benger J. Who does what in prehospital critical care? An analysis of competencies of paramedics, critical care paramedics and prehospital physicians. Emerg Med J. 2014; 31: 1009-1013 Crossref PubMed Scopus (25) Google Scholar Interestingly, of the interventions that define ALS, only high quality chest compressions and early defibrillation have been consistently shown to improve survival, while the benefits of advanced airway management and intravenous drugs are debated widely. 7 Jentzer J.C. Clements C.M. Wright R.S. White R.D. Jaffe A.S. Improving survival from cardiac arrest: a review of contemporary practice and challenges. Ann Emerg Med. 2016; PubMed Google Scholar Because the presence of a prehospital physician will increase costs in many EMS, this approach needs to have a positive impact on patients and/or the EMS as a whole. 8 Yen Z.S. Chen Y.T. Ko P.C. et al. Cost-effectiveness of different advanced life support providers for victims of out-of-hospital cardiac arrests. J Formos Med Assoc. 2006; 105: 1001-1007 Abstract Full Text PDF PubMed Scopus (21) Google Scholar With survival rates from OHCA remaining variable and generally low, exploring the optimal configuration of prehospital care for OHCA is an important step to improving outcomes. 4 Perkins G.D. Lockey A.S. de Belder M.A. Moore F. Weissberg P. Gray H. National initiatives to improve outcomes from out-of-hospital cardiac arrest in England. Emerg Med J. 2016; 33: 448-451 Crossref PubMed Scopus (53) Google Scholar , 7 Jentzer J.C. Clements C.M. Wright R.S. White R.D. Jaffe A.S. Improving survival from cardiac arrest: a review of contemporary practice and challenges. Ann Emerg Med. 2016; PubMed Google Scholar